MANOMETRIC IDENTIKIT OF A FUNCTIONING AND EFFECTIVE FUNDOPLICATION IN THE HIGH-RESOLUTION MANOMETRY ERA

Introduction
Toupet fundoplication (TF) has been shown to have fewer adverse effects compared to Nissen fundoplication (NF), however, it is unknown whether the advantages of TF persist when comparing outcomes by the distensibility of post-fundoplication lower esophageal sphincter (LES). Therefore, we aimed to compare quality of life (QOL) outcomes between NF and TF according to distensibility index (DI) measured by intraoperative endoluminal impedance planimetry.

Methods
This is a retrospective study of a prospectively maintained database of patients who underwent laparoscopic NF or TF, intraoperative EndoFLIP, and self-reported QOL outcomes postoperatively at 3-weeks, 6-months, 1-year, and 2-years using RSI, GERD-HQRL, and dysphagia surveys. Comparisons were made using chi-square and Wilcoxon rank-sum tests.

Results
From 2018 to 2021, 303 patients were analyzed (68% female) who underwent NF (n=80) and or TF (n= 223) for treatment of GERD, including paraesophageal hernia which represented 65% of cases. Of those who returned postoperative surveys, at 30mL fill-volumes, there were a total of 20 NF versus 25 TF with DI <2.0mm²/mmHg, 32 NF versus 71 TF with DI 2.0-3.5mm²/mmHg, and 13 NF versus 89 TF with DI>3.5 mm²/mmHg. At the optimal DI range of 2.0-3.5 mm²/mmHg at 30mL fill, no statistical differences were found on analysis at 3-weeks, 6-months, 1-year, and 2-year timepoints when evaluating RSI, GERD HQRL, gasbloat, and dysphagia scores. No statistical differences were found on QOL comparisons of NF versus TF within DI ranges <2.0mm²/mmHg or DI> 3.5mm²/mmHg at any timepoint (Table 1). At 40ml fill volume, there was a total of 20 NF versus 25 TF at DI < 2.0mm²/mmHg, 32 NF versus 71 TF with DI 2.0-3.5 mm²/mmHg, and 13 NF versus 89 TF at DI >3.5 mm²/mmHg. Analysis of postoperative surveys demonstrated no statistical differences when comparing RSI, GERD-HQRL, gasbloat and dysphagia scores of NF versus TF according to DI range <2.0mm²/mmHg, 2.0-3.5mm²/mmHg (Figure 1), or >3.5mm²/mmHg at any postoperative timepoint.

Conclusion
Impedance planimetry appears to be an objective measure of the physiology of the LES before, during, and after fundoplication. NF is comparable to TF when compared according to DI range, suggesting that QOL outcomes are dependent on post-fundoplication LES distensibility rather than type of fundoplication.

Background: Assessing patients following Laparoscopic Fundoplication (LF) can be challenging. The role of High-Resolution Manometry (HRM) performed after LF is still unclear and debated. We sought to determine the HRM parameters of a functioning fundoplication and evaluate whether HRM could discriminate it from a tight or a defective one.

Methods: Patients who underwent laparoscopic Nissen (LN) or Toupet (LT) fundoplication for GERD between 2009-2022 were included. Symptoms were scored using a dedicated symptom score (SS). HRM and 24-h pH monitoring (pH) were performed before and 6 months after surgery, regardless of patients’ symptoms; > 3cm hiatal hernias were excluded. LF failure was defined as GERD symptom recurrence (SS >8) and/or an abnormal 24h-pH. The study population was divided in 5 groups: LN and LT patients with normal 24h-pH (LN pH- and LT pH+, respectively), LN and LT patients with pathological 24h-pH (LN pH+ and LT pH+ groups, respectively) and patients having a postoperative dysphagia score with an intensity > 2 (Dysph group). LES parameters (resting pressure, IRP, total and abdominal length), and esophageal body function were reviewed by 2 experts (RS,GC). Differences in the postoperative HRM metrics between groups were evaluated, irrespective of preoperative ones.

Results: During the study period, 123 patients (M:F=84:39) having pre- and postoperative HRM were recruited (figure 1): 89 showed no objective sign of GERD recurrence after LN (LN pH-: 41 patients) or LT (LT pH-: 48 patients); 21 showed an abnormal postoperative 24h-pH after LN (LN pH+: 15 patients) and LT (LT pH+: 6 patients). Five patients (all had LN) reported postoperative dysphagia (Dysph). Eight patients with GERD symptoms despite a normal 24h-pH were excluded from further analysis. LES resting pressure and total and intra-abdominal lengths were significantly lower in the LN pH+ group compared to the LN pH-, as well as LES resting pressure and abdominal length in the LT pH+ group compared to the LT pH-. The percentage of ineffective swallows was significantly higher in the LT pH- compared to LN pH-. No other differences were detected in the esophageal body motility. Furthermore, LT pH- patients showed a significantly lower LES resting pressure and IRP compared to LN pH-. Conversely, IRP was significantly higher in Dysph compared to LN pH-. All data are showed in table 1.

Conclusion: This study provides the benchmark HRM values for an effective LF and confirms that the evaluation of the neo-sphincter with HRM improves the clinical assessment of symptoms recurrence and can discern patients with a well-functioning wrap from those showing GERD recurrence for an ineffective one. Moreover, IRP significantly correlated with the occurrence of postoperative dysphagia. Even if effective, LT was associated with significantly lower LES resting pressure and IRP than LN.